Provider Demographics
NPI:1689755274
Name:RAINBOW PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:RAINBOW PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:KUTUGATA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:956-969-2904
Mailing Address - Street 1:902 S AIRPORT DR STE 1
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6649
Mailing Address - Country:US
Mailing Address - Phone:956-969-2904
Mailing Address - Fax:956-969-1650
Practice Address - Street 1:902 S AIRPORT DR STE 1
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6649
Practice Address - Country:US
Practice Address - Phone:956-969-2904
Practice Address - Fax:956-969-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG9139208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85M551OtherBC/BS OF TEXAS
TX65128OtherSTAR PLUS PROGRAM
TXE14321Medicare UPIN